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  <form class="jotform-form" action="http://submit.jotformz.com/submit/23337306045649/" method="post" name="form_23337306045649" id="23337306045649" accept-charset="utf-8">
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        <ul class="form-section" >
      <li class="form-line" id="id_39">
        <label class="form-label-top" id="label_39" for="input_39">
          21- Como você classificaria os cuidados que tem tomado com a sua saúde de uma forma Geral ?<span class="form-required">*</span>
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          <div class="form-single-column"><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_39_0" name="q39_21Como" value="Excelente" />
              <label for="input_39_0"> Excelente </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_39_1" name="q39_21Como" value="Muito Boa" />
              <label for="input_39_1"> Muito Boa </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_39_2" name="q39_21Como" value="Boa" />
              <label for="input_39_2"> Boa </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_39_3" name="q39_21Como" value="Razoável" />
              <label for="input_39_3"> Razoável </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_39_4" name="q39_21Como" value="Ruim" />
              <label for="input_39_4"> Ruim </label></span><span class="clearfix"></span>
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      <li class="form-line" id="id_40">
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          22- Como você classificaria os cuidados que tem tomado com a sua saúde da boca ?<span class="form-required">*</span>
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          <div class="form-single-column"><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_40_0" name="q40_22Como" value="Excelente" />
              <label for="input_40_0"> Excelente </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_40_1" name="q40_22Como" value="Muito Boa" />
              <label for="input_40_1"> Muito Boa </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_40_2" name="q40_22Como" value="Boa" />
              <label for="input_40_2"> Boa </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_40_3" name="q40_22Como" value="Razoável" />
              <label for="input_40_3"> Razoável </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_40_4" name="q40_22Como" value="Ruim" />
              <label for="input_40_4"> Ruim </label></span><span class="clearfix"></span>
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              Voltar
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              Próximo
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